Are women still getting delayed ECGs in EDs?
Women may wait longer for ECGs than men, according to a new study.1 Jessica Zègre Hemsey, RN, PhD, the study's lead author, says she found the findings surprising because the American College of Cardiology/American Heart Association gives acquiring an initial ECG within 10 minutes of arrival to the ED a Class I recommendation.
"Our study found that not only was the mean time to initial ECG suboptimal for all patients, with a mean of 45 minutes, but women had a significantly longer time to initial ECG than men," says Zègre Hemsey.
Since women are more likely to present with atypical symptoms such as jaw pain, diaphoresis, and shortness of breath than men, ED nurses must recognize such differences and act upon them, says Zègre Hemsey.
"Triage systems need to be evaluated in order to optimize prompt initial ECG acquisition," she says. "Perhaps different triage protocols by gender need to be considered."
Use real-life examples
"This isn't a new issue for emergency nurses. We've heard a lot about the door-to-ECG in women issue," says Jim House, RN, BSN, CEN, director of emergency services at Ochsner Medical Center-Kenner in New Orleans, LA. "Obviously, men and women have different presenting symptoms."
Risk factors are one thing they do have in common, though, emphasizes House, such as medical history, social history, smoking, and high cholesterol. "Those are all little red flags that make you pay attention," he says. "The other thing I preach to my staff is to pay attention anytime someone says 'I have diabetes.' We all know that diabetics do not present with classic symptoms."
Probe into the quality and type of pain your patient is having, advises House, such as epigastric pain or intrascapular pain. When educating front-line staff, House discusses actual cardiac patients seen in the ED who came in with atypical presentations. "It may be that we missed the door-to-ECG time with Mrs. Smith, but she turned out to be an [ST-elevation myocardial infarction]," he says. "Using real-life examples enlightens them and drives change."
Pinpoint vague symptoms
Diane Liebeskind, RN, CEN, assistant nurse manager of emergency services at Jefferson Memorial Hospital in Ranson, WV, says to ask these triage questions:
- Are you having any chest pain or pressure, radiation of pain, nausea, shortness of breath, sweating, irregular heartbeats, dizziness, or extreme fatigue?
- Do you smoke cigarettes, drink alcohol in excess, or use recreational drugs?
- Do you have any family history of cardiac problems?
- Are you diabetic?
- When did the pain start and what were you doing at the time?
- What makes the pain worse or better?
"Any person over the age of 18 years without any other cause for the above symptoms should have an ECG within 10 minutes of arrival to the ED," says Liebeskind.
Liebeskind says that she herself is a good example of a woman presenting to an ED with vague symptoms, after becoming nauseated at work but with no chest pain. "I thought it was a virus, but my coworkers insisted that I be seen by the ED doctor due to my diabetes and significant family history," she says. "I eventually wound up in the cardiac cath lab with a major cardiac blockage."
- Hemsey JZ, Sommargren CE, Drew BJ. Initial ECG acquisition within 10 minutes of arrival at the emergency department in persons with chest pain: Time and gender differences. Journal of Emergency Nursing 2011; (37) 1:109-112.
For more information on avoiding delays in obtaining ECGs, contact:
- Erin Cavanagh, RN, BSN, MBA-HCM, Clinical Coordinator, Emergency Department, Henry Ford Hospital, Detroit, MI. E-mail: ECAVANA1@hfhs.org.
- Jessica Zègre Hemsey, RN, PhD, University of California, San Francisco. E-mail: firstname.lastname@example.org.
- Jim House, RN, BSN, CEN, Director of Emergency Services, Ochsner Medical Center-Kenner, New Orleans, LA. Phone: (504) 712-8841. E-mail: email@example.com.
- Diane Liebeskind, RN, CEN, Assistant Nurse Manager, Emergency Services, Jefferson Memorial Hospital, Ranson, WV. Phone: (304) 728-1695. E-mail: firstname.lastname@example.org.
Patients may not tell you they're having chest pain
If a patient insists the sole reason for coming to the ED is hand pain, probe further if his or her appearance doesn't match the complaint. "Look at the patient. No matter what the patient signs in as, if you see a patient who looks gray, sweaty, pale, and is breathing heavily, there are a lot of danger signs there," says Erin Cavanagh, RN, clinical coordinator in the ED at Henry Ford Hospital in Detroit, MI. "They need immediate attention."
You may learn that the patient's whole arm is hurting, and that she also has chest pain, says Cavanagh. "Sometimes some of the sickest patients do not give you as much detail as less acuity patients," she adds.
On the other hand, patients may look fine and still have a cardiac condition, says Cavanagh. "I've had lots of patients that look good, with pinkish color and dry skin, but they still have chest pain," she says. "One of the things we do not do here is pick out priority levels based on whether the patient is a man or woman. They are equally at risk for having a heart attack."
According to Cavanagh, the first person a patient sees when walking in the door should be an ED nurse, as opposed to a registration person or security. "The first person to eyeball them should be an ED nurse," she says. "It takes a skilled health care provider to know the difference between a cold symptom and a cardiac condition."
The ED cares for an inner city population with patients often presenting with multiple problems, says Cavanagh, and may not report chest pain specifically. "They may come in complaining of shortness of breath," she says. "When you dive deeper, you find out they are out of their medications, they missed dialysis--and they also have chest pain."
Want to know current meds? Ask it this way
If you ask a chest pain patient, "What medications do you currently take?" and he or she tells you "none," don't stop there, says Erin Cavanagh, RN, clinical coordinator in the ED at Henry Ford Hospital in Detroit, MI. "Quite often, when I ask a patient if they have any medication history, they say no. If I ask them if they're taking any medications, they also say no," she says.
However, when Cavanagh asks the patient, "Has a doctor prescribed you medications?" the patient may answer yes. "The patient might not be able to afford the medications, or may have run out of them," she says.